Private Intake Form

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Private/Semi-Private Intake Form

We are so very much looking forward to joining you on your journey to parenthood.

Please take a few minutes to read the Terms of Service and fill out the form below:

Click here to Read the terms of service

* Indicates required field

Name *

First

Last

Email *

Phone Number *

Your Pronouns *

Birth Partner Name (if you have one) *

First

Last

Partner's Email *

Partner's Phone Number *

Partner's Pronouns *

Address *

Line 1

Line 2

City

State

Zip Code

Country

What is your estimated due/guess date? *

Is your education taking place in your home, or on zoom? *

In Our Home Online, zoom

Who is your Educator? *

Who is your medical care provider? Please include their name/group name. If your current care provider isn't your first choice, please state who you would prefer. *

Your chosen birth location (Hospital, Home, Undecided) *

If birthing in hospital, please include the name of the hospital. If you are undecided, please let us know.

What are your primary concerns for this pregnancy and birth? *

What do you want to get most out of this class? *

Do you have any additional support people? *

Do you have a doula, chiropractor, naturopath, counsellor, spiritual advisor etc)

Before we start working together, is there anything else you would like to share? *

Where did you hear about us? *

Instagram Facebook Google Doula/Midwife/Doctor/Allied-Health Professional Other

I have read and agree to the Terms of Service. *

Yes I agree No I do not agree

Click button above to read the Terms of Service

I agree to receiving marketing and promotional materials

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Name *

First

Last

Email *

I agree to receiving marketing and promotional materials *

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@mypowerfulbirth

My Powerful Birth welcomes all families.

My Powerful Birth team is grateful to live, work and raise our children on the
unceded, ancestral lands of the Coast Salish and Sto:lo peoples.

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